1. Cervical Rib Syndrome - A Case Report - Sung Soo Kim, M.D. Hyeong Cheol Ryu, M.D. Department of Orthopaedic Surgery, School of Medicine, Dong-A University, Busan, Korea.

2. Case Report F/16 C/C: Pain on both lateral neck esp. when raising arms D: 2 years (1 year ago, symptoms aggravated especially on left side and radiating pain to elbow) P/H: N-C

3. Case Report P/Ex: –Palpable bony prominence on both lateral neck(esp. Lt.) –Tenderness(+/++) –Radiating pain on arm(+/++) –Lt. 4 th & 5 th fingers: sensory decreased & tingling sensation –Adson test(-/+) –LOM on neck: mild –Thrill(-/-), muscle atrophy(-/-), DTR(NL/NL) EMG/NCV: WNL

4. Roentgenograph

5. 3-dimensional CT

6. Treatment Rt.: conservative Tx. Lt.: surgery –Supraclavicular approach –Release of ant. scalene muscle –Removal of 7 th cervical rib

7. Operative Findings

8. Postop Roentgenograph

9. Postop Care POD 2: intermittent shoulder exercise start Adson test at POD 2: Lt.(-) Sx.: radiating pain & tingling sensation -> improved Cx.: none

10. Cervical Rib Syndrome Scalene space, interscalene triangle –clavicle, first rib, ant. & middle scalene muscles Thoracic outlet syndrome –Cervical rib syndrome –Scalenus anticus syndrome –Costoclavicular syndrome –Hyperabduction syndrome

11. Cervical Rib Syndrome 1740 Hunauld; first reported 1860 Willshire, 1869 Gruber; conception for diagnosis 1861 Coote; first surgical removal of cervical rib

12. Cervical Rib Syndrome Sx. –Nerve compression Sx.(MC) Traction & compression: C8, T1 nerve root(lower trunk) Pain on neck & shoulder Radiating pain, paresthesia & numbness: median & ulnar nerve dermatome –Arterial compression Sx. Pain, claudication, pallor, Raynaud phenomenon Peripheral embolism –Venous compression Sx. Coolness, duskiness, venous dilation, edema Subclavian vein thromboembolism, peripheral necrosis

13. Costoclavicular Syndrome

14. Cervical Rib Syndrome Dx. –Adson test, Wright test and hyperabduction test etc.(But positive to normal person) –Roentgenogram, CT, MRI –Angiogram, Doppler test –Myelogram –EMG/NCV

15. Cervical Rib Syndrome Davis & King –Symptom developed third & fourth decade Delayed ossification of cervical rib Delayed developmental completion Descending shoulder girdle(esp. scalenus anticus syndrome: middle aged female)

16. Cervical Rib Syndrome Tx. –Conservative Tx. Postural correction Physical therapy: sternoclavicular joint & acromioclavicular joint exercise, scalene muscle & pectoral muscle stretching -> costoclavicular space widening Shoulder muscle strengthening & home exercise program

17. Cervical Rib Syndrome Tx. –Surgical Tx.: no improve to conservative Tx. Supraclavicular approach Supraclavicular & post. parascapular approach Transaxillary approach (Ant. Scalene muscle, middle scalene muscle, cervical rib, first rib & part of clavicle)

18. Cervical Rib Syndrome Cx. –Brachial plexus injury –Subclavian vessels injury –Phrenic nerve injury –Perforation of pleura –Bleeding & hematoma –Infection

19. Thank you for your attention